My talk for emergency nurses on managing post cardiac arrest syndrome.

1. When you get one
Back.
Post Cardiac Arrest Syndrome!
By Kane Guthrie
S

2. Learning Points
S Cardiac arrest were are we at?
S A case!
S Post resuscitation care is it the answer?
S A chilling look at the benefits of therapeutic hypothermia!

3. Cardiac Arrest the Stat’s
S Generally 6-7% survival rate (worldwide)
S 0nly 3-4% leave hospital with RONF
S Early Defib/compressions make the difference
S Post resuscitation care is the answer to improving
mortality and morbidity with ROSC.

4. Cardiac Arrest
S We loose so many!
S We need to focus on the ones we get back.
S The REAL resuscitation starts once we get ROSC!
S RONF or organ donation is the only good outcome’s!

5. The Approach

6. The things that help get em
back!
The 3 things that have the evidence:
1. Early high quality chest compressions
2. Early defibrillation
3. Therapeutic hypothermia

7. Case Study
S 68 male walking home from pub
S Collapse > Cardiac Arrest >Bystander CPR
S SJA arrive 13mins post arrest
S In VF, Successful ROSC post x3 defibs
S Arrives in T2 20 mins later with no RONF
S What should we do now?

8. Remember!

9. The Goals Post Arrest
1. Induce Therapeutic Hypothermia
2. Maximise Haemodynamic’s
3. Optimise Oxygenation
4. Advocate for Cardiac Catheterisation

10. Post Cardiac Arrest
Syndrome!!
S Thought to be RT production of free radicals
S Pathophysiology is very complex = BORING
S Hypoperfusion & Ischaemia cause cascade of events
1. Disruption of homeostasis
2. Free radical formation
3. Protease activation
•Hypothermia helps slow down this cascade

11. The Patho
1. Brain Injury
S Cerebral oedema and ischaemia
2. Myocardial dysfunction
S Haemodynamically labile R/T global hypokinesis.
3. Systemic ischemia/reperfusion response
S SIRS response – looks like sepsis.
4. Persistent precipitating pathology.
S The underlying cause.

12. Oxygen and Ventilation
Avoid hyperoxia:
S O2 toxicity detrimental to heart and brain.
S Adjust 02 to keep spo2 >90.
Avoid hyperventilation:
S Hypocarbia causes cerebral vasoconstriction.

13. Circulatory Support
S Haemodynamic instability is the norm!
S Each episode of hypotension worsens mortality & neuro
function.
S Aggressive IVF- replace volume depletion
S Keep MAP- 65-100mmHg (adrenaline, noradrenaline or
dopamine)

14. ICU via Cath Lab?
S PCI improves survival and neurological function.
S STEMI should go straight to CATH Lab.
S Consider for all other survivors within 12-24 hours post
ROSC – up to 40% have unstable plaques.
S Can be difficult convincing cardiology!!!

15. Therapeutic Hypothermia
S ‘Induced hypothermia” is were pt is deliberately cooled
between 32-33.9°C
S It aims to reduce hypoperfusion (& reperfusion) injury post
arrest.
S Focuses mainly on brain (neuroprotection), but offers protection
to heart, liver, kidneys.
S Current research shows no benefit of inducing TH before or
during event. (RINSE trial ongoing)

16. Therapeutic Hypothermia
S Therapeutic hypothermia is the first treatment that has
proven effective for post-resuscitation reperfusion injury.
S NNT 1:6 vs 1:42 for aspirin in STEMI

17. Who’s in? Who's Out?
In. Out.
S Cardiac arrest with ROSC. S Advanced directive or DNR.
S Persistent significant altered S Traumatic arrest.
GCS.
S Active bleeding.
S <12 since ROSC.
S Pregnant, recent major surgery
or severe sepsis.

18. 3 phases of TH.
1. Induction: •Aim reduce core temp to
32-34°C
•Preferably within 2 hours
2: Maintenance: •Maintain core temp 12-24
hours
3:Rewarming: •controlled or passive
rewarming to normothermia
37°C
•0.2-0.5°C per hour –over 8-
12 hours

19. How to Cool!
S Cold fluids
S ICE Packs
S Machine’s

20. ED Management
Airway •secure ETT, continuous
EtCO2
Breathing •Prevent VILI
Circulation •ECG (risk arrhythmias)
•Monitor U/O (cold diuresis)
Disability •Paralyze, sedate
Exposure •Core temp monitoring
•Monitoring skin integrity
•Once at 34°C remove ICE
packs & maintain
•Monitor and prevent
shivering
•Prepare patient for T/F to ICU, Cath Lab

21. Monitoring the bloods

22. Remember the basics
S Pressure area & skin care
S Adequate sedation/analgesia
S Lung protective ventilation
S Seizure control
S Social support (family)

23. Complications
S Tachycardia > bradycardia
S Hypertension
S Diuresis (hypovolaemia)
S Shivering (increases temp)
S Arrhythmia's
S Increase bleeding
S Spiking temp’s look for signs of infection

24. Case Continued
S Pt intubated and ventilated in ED
S Cooling began.
S Taken to CATH lab 90% occlusion to LAD.
S Warmed and extubated 24 hours later in ICU.
S GCS 15
S Back at the pub 4/7 later.

25. The Future

26. Take Home Points
S Good post resus care improves outcomes.
S Therapeutic hypothermia should be done on all ROSC
with-out RONF.
S Maximise haemodynamic’s and oxygenation in ED.
S Advocate for the early CATH Lab.

27. Thank-you